The dietitian will need to know the client’s diet history, food likes and dislikes, and lifestyle at the onset. The client’s calorie needs will depend on age, activi-ties, lean muscle mass, size, and REE.
It is recommended that carbohydrates provide 50% to 60% of the calories.
Approximately 40% to 50% should be from complex carbohydrates (starches).
The remaining 10% to 20% of carbohydrates could be from simple sugar.
Research provides no evidence that carbohydrates from simple sugars are digested and absorbed more rapidly than are complex carbohydrates, and they do not appear to affect blood sugar control. It is the total amount of carbo-hydrates eaten that affects blood sugar levels rather than the type. Being able tosubstitute foods containing sucrose for other carbohydrates increases flexibility in meal planning for the diabetic.
Fats should be limited to 30% of total calories, and proteins should provide from 15% to 20% of total calories. Lean proteins are advisable because they contain limited amounts of fats.
Regardless of the percentages of energy nutrients prescribed, the foods ultimately eaten should provide sufficient vitamins and minerals as well as energy nutrients.
The client with type 1 diabetes needs a nutritional plan that balances calories and nutrient needs with insulin therapy and exercise. It is important that meals and snacks be composed of similar nutrients and calories and eaten at regular times each day. Small meals plus two or three snacks may be more helpful in maintaining steady blood glucose levels for these clients than three large meals each day.
The client with type 1 diabetes should anticipate the possibility of missing meals occasionally and carry a few crackers and some cheese or peanut butter to prevent hypoglycemia, which can occur in such a circumstance.
The client with type 2 diabetes may be overweight. The nutritional goal for this client is not only to keep blood glucose levels in the normal range but to lose weight as well. Exercise can help attain both goals.
Carbohydrate counting is the newest method for teaching a diabetic client how
to control blood sugar with food. The starch and bread category, milk, and fruits have all been put under the heading of “carbohydrates.” This means that these three food groups can be interchanged within one meal. One would still have the same number of servings of carbohydrates, but it would not be the typical number of starches or fruits and milk that one usually eats. For example, one is to have four carbohydrates for breakfast (2 breads, 1 fruit, and 1 milk). If there is no milk available, a bread or fruit must be eaten in place of the milk. The exchangelists are utilized in carbohydrate counting as well as in traditional meal planning. Protein, approximately 3 to 4 ounces, is eaten for lunch and dinner. One or two fat exchanges are recommended for each meal. Two carbohydrates should be eaten for an evening snack. These are only beginning guidelines. A dietitian or diabetic educator can help tailor this to the individual client.
The method of diet therapy most commonly used for diabetic clients is that based on exchange lists. These lists were developed by the American Diabetes Association in conjunction with the American Dietetic Association and are summarized in Table 17-2 and included completely in Table 17-3.
Under this plan, foods are categorized by type and included in the lists in Table 17-3.
The foods within each list contain approximately equal amounts of calo-ries, carbohydrates, protein, and fats. This means that any one food on a particular list can be substituted for any other food on that particular list and still pro-vide the client with the prescribed types and amounts of nutrients and calories.
The amounts of nutrients and calories on one list are not the same as those on any other list. Each list includes serving size by volume or weight and the calorie value of each food item, in addition to the grams of carbohydrates, and, when appropriate, proteins and fats. The number of calories needed will determine the number of items prescribed from any particular list. These lists also can be used to control calorie content of diets and are thus appropriate for low-calorie diets.
The total energy requirements for adult diabetic clients who are not overweight will be the same as for nondiabetic individuals. When clients are overweight, a reduction in calories will be built into the diet plans, typically allowing for a weight loss of 1 pound a week.
The diet is given in terms of exchanges rather than as particular foods. For example, the menu pattern for breakfast may include 1 fruit exchange, 1 meat exchange, 2 bread exchanges, and 2 fat exchanges. The client may choose the desired foods from the exchange lists for each meal but must adhere to the specific exchange lists named and the specific number of exchanges on each list. Vegetables (nonstarchy) are relatively free and can be eaten in amounts up to 11⁄2 cups cooked or 3 cups raw. If more than this amount is eaten at one meal, count the additional amount as one more carbohydrate. Snacks are built into the plan. In this way, the client has variety in a simple yet controlled way.
When there are changes in one’s physical condition, such as pregnancy or lactation, or in one’s lifestyle, the diet will need to be modified. A change in job or in working hours can affect nutrient and calorie requirements. When such changes occur, the client should be advised to consult her or his physi-cian or dietitian so that calorie and insulin needs can be promptly adjusted.